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Tuesday, November 18, 2014

Cervical cerclage (stitch) at 15 weeks

When the cervical swab which my gynecologist took came back positive for Staphylococcus aureus (a bacteria which is not usually present in vagina) she called me. She said that there was only very small amounts of bacteria found (it can also just be a contamination from elsewhere since S.aureus is a normal skin flora) and it was not something that was serious enough to stop the cerclage procedure. She gave me a local vaginal disfectant (a pessary) and asked me to insert in the vagina once a day. I had 5 more days left for the cerclage. In the clinic, they have also given me clindamycin (antibiotic), which I have to take for 7 days. My cerclage was scheduled on a Monday morning. Rjender was worried about my swab result. He was telling me, "the clinic people will make a big fuss about this swab result, perhaps they won't do the cerclage on Monday because of it". I thought his worry was unnecessary. But, on Friday evening, I got a call from the clinic. An intern physician talked to me. She said, "I saw your swab result and you can't have your cerclage on Monday morning". I was so upset and irritated. I was taking antibiotic and that local disinfectant as instructed, whatelse do they need to kill that stupid microbe! Already I was 15 weeks pregnant (cerclages done before 16 weeks are less risky), and one more concern was that the doctor who will be doing my cerclage will be on holiday the following two weeks. I told her that I was taking antibiotic. Her reply was, "Sorry, we can't perform a cerclage without another swab which comes back clear". I don't know how to convince her. I demanded that I want to meet the doctor who will be doing my cerclage. She said that he will be available only on Monday morning. She suggested me to come to operation theater directly on Monday morning and talk to him. I thought, if I meet the doctor directly I will convince him for the cerclage. I talked to Anju (my sister) who is a gynecologist too. She was upset too, she said, "We perform cerclages all the time. We never do a cervical swab. After cerclage we just give them IV antibiotic and send them home. I have never seen one adverse outcome (infection due to cerclage) in our setting ( she works in an Indian government hospital!)".

So on Monday morning we got ready and went to the clinic. From the moment I entered the clinic, I was asking the nurses there whether the doctor who will be performing the cerclage knows that I have come for the operation. Everyone's answer was yes. So I relaxed a bit. I thought might be the surgeon decided that my swab result was not a concern and decided to proceed with the surgery. They prepared me for the surgery. I wore a special gown in which I appeared like a clown. They brought a nice hospital bed and wheeled me to the operation theater. I waved good bye to Rajender; the thought whether I would see him again flashed within me as always. I have gone under anesthesia umpteen times in these 7 years and I was always lucky enough to see him again! I smiled and took leave from him, he planted a kiss on my forehead. Such loving gestures are the ones we remember most than the intimacy we enjoy during happy times, don't we? Sometimes, however scary the ordeal may be, when I will be wheeled down to the OT a kind of childish excitement takes over me as if I am entering a brand new world. I was not tensed a bit, I know I will be having spinal anesthesia and I was looking forward to the experience. I was wondering who will be in the theater and how will the surrounding be! The only thing that was disturbing me was, they didn't do a scan to check the baby or the cervix before taking me to the OT. I thought might be in OT they have an ultrasound machine. I noted in my mind that I must ask for a scan if they didn't do it before the operation.

When I reached the operation theater the nurses there was not happy with my attire. They brought a different gown, put me into that, and took me to the theater. The first face I saw was a very familiar one. My face bloomed with a smile. There stood the anesthesiologist, who was my colleague, my friend, whom I met in lab while I was doing my PhD. He was working for his doctor thesis in the same lab. We got to work together. He has come to our home with his girlfriend, we went to his place. He was such a pleasant person and my worry was halved on seeing him. He said he was the one who will be administering me spinal anesthesia. I was so relieved. They connected me to ECG leads and blood pressure monitoring instrument. Then the anesthesiologist asked, "Can I give you the anesthesia now?" I told him, "Please wait I want to meet the surgeon first, I need to ask him something". I told the anesthhesiologist about the swab and what the intern doctor said. So they waited for few more minutes and again he came to me. He said, "I will give you anesthesia first, since it is only spinal you can talk to the doctor after he comes". That was ridiculous, I thought. In case if the surgeon doesn't want to perform the surgery, why should I go under anesthesia unnecessarily! I told him this and he called the surgeon via mobile. After sometime the surgeon came with a warm smile. He asked what the matter was. I asked him whether he has seen the swab result and he was totally clueless about it! He looked at me with a confused look and asked the result of the cervical swab test to me. I was taken aback. I told him that they found Staphylococcus in it. He asked me again whether it was coagulase positive or negative bacteria. I asked what difference it would make to the surgery. He said if it was coagulase positive bacteria he wouldn't perform the surgery! I didn't want to tell him it was S. Aureus. I wanted him to know the result by himself. So he left the room in search of the result and came back after 30 minutes or so. I was chatting with my anesthesiologist friend until then. I expressed my concern over how unorganized they were and how they didn't even bothered to look at the baby before bringing me to OT. The surgeon came after 30 minutes and said, "Sorry I can't do the surgery today, it was S.Aureus and it is a coagulase positive strain". Lying down on the operation table, I argued that I was on antibiotic and have taken the local vaginal antiseptic too. I told him what Anju told me - how in India they perform cerclage without a cervical swab. He came near me and spoke in a soft voice. "I understand your fear. But, the climate in India is very different from here. Your amniotic fluid is in German climate. This S. Aureus is an extremely blood loving bacteria. It is very dangerous to do the surgery without another swab to make sure it is gone. You haven't yet completed the full course of antibiotic". I expressed my concern that he will not be available for the next two weeks and I am already in my 15 th week of pregnancy. He said, " Come tomorrow morning, I will take a cervical swab once again. I will make sure we get the result as quick as possible so that you can have the cerclage on Thursday or Friday". He promised me he will do the cerclage. I said good bye to everyone there. The anesthesiologist assured that he will be there on Thursday and Friday too. I was wheeled again to my room. Rajender was surprised to see me so early. I explained him everything. I changed to my clothes and took leave from the nurses.Thus ended my first attempt of having a cerclage :)

Next day I went to the clinic and they took another swab. Everytime they disturb my cervix I feel so uncomfortable. I made sure they used sterile speculum everytime. Some doctors without the least concern use the speculum whatever they get in hand. When it will be too big it made me scream with pain, all they would say is, "Please relax!" (afterall it's your fault!). When will my life become free of stirrups and speculums?

The results came on Wednesday. That afternoon I received a call saying that I can come on Thursday morning for surgery as the swab came back clear. This time I was given an ultrasound scan (to confirm baby's heartbeat) before preparing me for the surgery. I was wheeled to the operation theater. Anesthesiologist was waiting. I was given a spinal anesthesia. The anesthesia procedure was not painful but uncomfortable. I just prayed that they don't paralyze me by mistake. Within a few minutes lower portion of my body started to become numb. I couldn't feel my lower portion and it felt funny. They lifted my legs on to stirrups. I could hear nurses talk as they were preparing me for the surgery. The room was a bit cold. Anesthesiologist was talking to me now and then. One or the other person was coming near me every few minutes and asking whether I was ok. Anesthesiologist asked whether he could give me some medicine in IV so that I could sleep. I hated that idea. I wanted to be awake, I felt, by being awake, I have some control over the surgery; I wanted to stay awake to protect my little one. I believed that they will be more careful if I was awake. The surgeon came. He wanted to do a Shirodhkar cerclage which is more invasive than Mc Donald's cerclage (there are different kinds of cerclage, please wait for my post on cerclage). Dr. Malpani also wanted me to have a Shirodhkar cerclage as it will placed a little higher than Mc Donald's, and since the sutures run within the cervical muscles the chance of infection is lower too. I told the doctor to be very careful. He smiled assuringly and disappeared behind the screen which shielded my vision from what is happening in my nether region. The doctor has bought two interns too with him. I could hear him asking for specific surgical instruments to the nurses; I could hear him continuously instructing the interns which at times left me in panic. I wondered whether he is allowing them to handle the cerclage procedure. I wanted to say no but I decided to have faith. I started to feel cold at one point and they circulated warm air through a plastic bag and kept it on my chest. That helped a lot. I also felt very nauseous sometime which faded away quickly. Spinal anesthesia is horrible and I wondered how good general anesthesia felt! I tried hard to distract myself. Catholics believe that every soul which enters this world is assigned a guardian angel. I imagined my guardian angel standing near me holding my hands. The angel had a beautiful smile which was so soothing to look at and had big compassionate eyes too. The angel's hand was soft and smooth. The fingers were long, mine appeared like a dwarf's comparitively. That imagination helped me to relax and distracted me from unnecessary fears. I closed my eyes and believed that all will be well. The surgery lasted for one hour.At the end of the surgery the doctor assured me that all went well. He also said that he found no problem with my cervix, it was long and strong at that point.

After the surgery I was wheeled back to the recovery room. I was waiting for my lower part to regain its senses. Everyone who were brought after me started to leave that room but my legs doesn't seem to move at all. As time went by I started to panic, "Will I regain my senses in my leg?". When I was wondering so, the atmosphere around me became restless suddenly. All the nurses there surrounded me quickly. There was some machine in one of the nurses hand. They started to remove the gown that covered the upper part of my body. I was wondering about the sudden attention I was getting. Someone spoke, "We need to take an ECG, you are having tachycardia, your heartbeat is in the 130 range. Please do not panic its just a precautionary check". I was baffled for a second and then asked them whether they are having me on tocolytic medicine (a drug to prevent uterus contraction). They checked and said yes. I relaxed, tocolytics naturally have the tendency to increase one's heart beat. When they tried to remove the cloth covering my upper body to fix the ECG leads, my hand automatically pulled the cloth up like a reflex action. Until they laughed I didn't understand what I was doing. Only when a male nurse there said, "Ok I will turn to the other side," I realized what I was doing. It was really humiliating. I wondered whether I was taught (by the society I grew up) to look at my body as mere sexual object! I have always admired the fact how women in western countries feel comfortable about their body! It took me almost 3 hours to move my legs. Once I proved the nurse that I could move my legs I was allowed to leave the recovery room. They wheeled me into a room where Rajender was waiting for me. I stayed there for 5 more days. I was given IV antibiotics. They checked my blood parameters for infection periodically. That hospital stay brought us all the memories of 10 horrible days I spent lying down with twins. It is the same for Rajender too. We were too afraid of everything that could go wrong. With twins, one fine night, one of my little one's amniotic sac broke. That was the most haunting experience for us. We were so afraid whether it will repeat again. A very small movement from me would wake Rajender up. He never left me alone in the hospital, he made sure that he stayed with me at nights. Although I felt safe I couldn't get comfortable in Rajender's presence. I have to think several time before I turn in bed. I would be worrying that it will wake him up. I understood his fear and anxiety. I saw him sleepless and paranoid. I insisted that he must stay at home but in vain. He carried(s) me and my little one in his head and heart always!

The hospital stay was eventless. They discharged me after 5 days with one more course of oral antibiotic to take for the next 7 days. Before that they did an ultrasound to confirm our little one was ok. The cerclage was a welcome relief for every one of my loved ones. I must thank the doctor for doing a wonderful job, the cerclage is holding on fine until now without further problems. Might be my cervical problem was just a twin thing, I will never know!

8 comments:

So happy to read Cerclage went good Manju! Take care of yourself and little one!When i read about the description of the Guardian Angel, it really misted my eyes. Sure, we all are with a Guardian Angel, it can be God, our Parents, Grand Parents or so..

I will be having my SEL tomorrow. Hope everything goes good. Take care all you lovely ladies here.

You are a really strong woman Manju, carrying a baby in the womb is anxiety enough let alone what you had to go through. I am super proud of you! Take care of yourself and the baby. Can't wait to know whether it is a boy or girl! Lots of love and hugs, Nio

Thanks Nio! But there are so many women who go through horrible ordeal to have a baby. When I read some of the mails I receive and the pain and despair they were in, it makes my heart so heavy. I wish I have a genie with me which will make all their dreams come true. We must all be very proud of ourselves.

Good to read that all went fine with ur cerclage Manju. Im also worried reading it now as im 11weeks pregnant with twins. Was ur cervix short?. Why was it done?. Or was it just a precautionary measure?. Is this problem of short cervix more common with twins?.when should one go for cerclage?.I would be into tears every time i read ur blog. U r strong, intelligent n courageous. Above all a wonderful soul. I dont know if ur hubby is luck to have u or u r more lucky to have him or ur baby is more lucky to have u guys as parents. U guys compliment each other. God bless u guys. Take care. My best wishes.

Do not panic. Just because something unfortunate happened to me or other pregnant women, it doesn't mean you will go through it too. But ignorance is evil and I appreciate your eagerness to know things and take precautions.

The cervix is the mouth of the uterus. Imagine a wine bottle's neck. Cervix is a structure similar to that. When a baby grows in the uterus, the uterus starts to expand to accomodate the growing baby. Because of this stretching some women's cervix is also pulled apart. Actually, as many think, it is not the weight of the baby bearing down on the uterus which causes cervical incompetence ( premature opening of the cervix). It is the stretching of the uterus which causes cervical incompetence. Just imagine a wine bottle expanding, naturally it's mouth starts to open as it expands.

Most women's cervix are strong enough to resist the stretching of the uterus. They remain tightly shut until the baby is ready to come out, that is, after 9 months. For some women the expanding uterus puts pressure on the cervix ( women who have had multiple intervension in their cervix, like abortions or who had some part of their cervix removed due to cervical cancer or for some unknown reason) and leads to premature opening of it. When the cervix opens in the part closer to the uterus it is called funneling and if it opens in the region which is extended into the vagina, it is called dilation.

What happens if it opens prematurely? The uterine environment is highly sterile. The tightly shut cervix prevents any infection from climbing from your vagina into the uterus. The tightly closed cervix also prevents the baby slipping out. Actually during earlier weeks if the cervix opens from inside, the amniotic bag could slip into the cervical opening. This can cause the bag to break open because of the pressure.

Is twin pregnancy at a higher risk of incompetent cervix. For some women perhaps yes. You must be careful if you had bleeding during early pregnancy ( it is more common with twins pregnancy) as I read this could weaken the cervix. The rapid stretching of uterus in multiple pregnancy and the presence of too much hormones could also pose a problem.

What precautions should you take? Ask your doctor to measure your cervix around 12 weeks using vaginal ultrasound. Then starting from 16 weeks every two weeks. This will give an idea about how your cervix is faring, whether it is shortening or not. If it changes drastically then they will ask you to have a cerclage. Remember, not every woman will have problem with cervix even if they carry twins. Unnecessary intervention to the cervix could cause more harm

http://www.keepemcookin.com/prevention.aspx

Please read the above link! It will give an idea about the cervix length at different stages of pregnancy.

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Disclaimer

Please note that I have no medical training or qualifications, and that the contents of this blog are thereof are opinions, not medical advice.

have medical training or qualifications, and that the contents thereof are opinions, not medical advice. - See more at: http://healthbeat.areavoices.com/2010/09/29/the-expert-patient/#sthash.YPxLA3EA.dpuf

have medical training or qualifications, and that the contents thereof are opinions, not medical advice. - See more at: http://healthbeat.areavoices.com/2010/09/29/the-expert-patient/#sthash.YPxLA3EA.dpufPlease note that I have no medical training or qualifications, and that the contents of this blog are thereof are opinions, not medical advice.

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I thrive on love and affection!

I am a 36 year old Indian woman, happily married for seven years. This blog captures the 7 year infertility journey we went through to have our daughter Anisha. I have to undergo7 IVF/ICSI cycles, three miscarriage (including a still birth where I lost my twins to incompetent cervix) and 3 FETs to have our little miracle in hand. This journey was excruciatingly painful at times yet shaped me in ways happy times wouldn't have. Looking back, I wonder about myself ! I feel proud that I was able to be sane and strong after so many IVFs and heartbreaking miscarriages. Now I am very happy and serene than if I would have had children without any problems ( a bit crazy too ! :) The secret is, infertility is a great teacher. It taught me to be strong, humble, resilient, rational, forgiving, empathizing and hopeful. BTW, I am a scientist by profession. I hold a doctorate degree in Human Biology and I believe my education has helped me to tackle infertility bravely. I would like to share my experience and knowledge which I gained during this happy struggle to meet our offspring with you all. If you could share with me your thoughts and experiences I will be very happy !